Epilepsy in Pregnancy. Sherifia Heron, M.D October 20, 2009 Ob Rotation Dept. of Family and Social Medicine. Case.
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36yo G1P0000 at 35wks and 2 days with history of epilepsy sent from clinic for elevated BPs to rule out preeclampsia. She had no complaints. No LOF, No VB, and +FM. No HA, Visual Changes, or epigastric pain.
Initial BP 110/60, Range (100-125/60-80), Total of 9 visits. Initial weight 128160 = 32lbs gained.
Several studies suggest that lamotrigine clearance increase by about 65 to 94% and therefore should be monitored more frequently during the second and third trimesters, to reduce the possibility of increased seizures, as well as in the early postpartum period, to avert toxicity
Among 14 women monitored on levetiracetam therapy during pregnancy, plasma concentrations were observed to decline during pregnancy to 40% of baseline concentrations in the third trimester. Limited information on seizure control was provided, but the possibility of increased seizures during this time suggests the need for closer monitoring
In one large pregnancy registry oxcarbazepine monotherapy increased the risk of seizure, suggesting the possibility that it, too, is associated with pharmacokinetic changes in pregnancy, and requires more frequent monitoring.
A study describing 12 women on topiramate therapy during pregnancy reported that serum concentrations declined by about 30%. Increased seizure frequency in pregnancy was also observed in this series
Status Epilepticus Status epilepticus is prolonged, repetitive seizure activity that lasts more than 20 to 30 minutes, during time which the patient is unconscious. Status epilepticus is a medical emergency with a significantly poor outcome; it can result in death if not treated aggressively. Its causes include improper use of certain medications, stroke, infection, trauma, cardiac arrest, drug overdose, and brain tumor
Many physicians will consider withdrawal of AEDs after a period of two years without seizures. The frequency of seizure recurrence within six and twelve months of discontinuing therapy is 12 and 32 percent, respectively.
Thus, if a woman has been seizure-free for a satisfactory period, a taper and withdrawal of AEDs at least six months prior to becoming pregnant is suggested
The most common major congenital malformations associated with AED are
congenital heart and urinary tract defects,
and cleft palate.
Specific AEDs, combination drug therapy, a family history of birth defects, and other risk factors appear to be associated with increased risk of these, at least in some studies
Particularly valporate and carbemazepine monotherapy,
benzodiazepines in polytherapy, and caffeine in combination with phenobarbital
In addition to the specific AED used alone or in combination, the gestational timing of the exposure and the dose of AED used are also likely to be important. These have been best associated with valporate
Many of these drugs appear to be implicated in dysmorphisms such as hypoplasia of the nails and distal phalanges, hypertelorism, and the “anticonvulsant face” – Broad or depressed nasal bridge, short nose with anteverted nostrils, long upper lip, maxillary hypoplasia
Most physicians recommend administration of prophylactic vitamin K during the last month of pregnancy to women treated with AEDs to protect the child against severe postnasal bleeding due to a deficiency in vitamin K-dependent clotting factors
Enzyme-induced AEDs, such as phenobarbital, phenytoin, and carbemazepine, cross the placenta and may increase the rate of oxidative degradation of vitamin K in the fetus, an effect that can be overcome by large doses of vitamin K
In addition to concerns about fetal exposure to antiepileptic drugs (AEDs), there are risks to the fetus from maternal seizures and maternal epilepsy.
Few studies have been performed on the direct effects of maternal seizures on the fetus.
One report of fetal heart rate monitoring during a maternal generalized tonic-clonic seizure lasting 2.5 mins revealed significant fetal heart rate deceleration lasting up to 30 mins after the seizure. While nonconvulsive seizures are believed to be less dangerous, another case report has documented significant fetal bradycardia during a one-minute, complex partial seizure.
Most women have a normal vaginal delivery. However, elective cesarean section may be justified in women with frequent seizures during the third trimester or a history of status epilepticus during severe stress
A tonic-clonic seizure occurs during labor in 1 to 2% of women with epilepsy, and in another 1 to 2% 24hrs after delivery. It is therefore essential to maintain a plasma AED level known to protect against seizures during the third trimester and during delivery.
Doses must not be missed during the period of labor.